Healthcare Provider Details

I. General information

NPI: 1477814739
Provider Name (Legal Business Name): MAHMOOD EL-GASIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

IV. Provider business mailing address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-1000
  • Fax: 602-508-4830
Mailing address:
  • Phone: 602-955-1000
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number53975
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number53975
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License Number53975
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: